OECD Health Policy Studies

This series of publications analyses the organisation and performance of health systems, and factors explaining performance variations. Studies are conducted on such topics as co-ordination of care, pharmaceutical pricing, long-term care and disability, health workforce and international migration of health workers, information and communications technologies in health care, and the economics of prevention.

Health workers are the cornerstone of health systems, playing a central role in providing health services to the population and improving health outcomes. The demand and supply of health workers have increased over time in all OECD countries, with jobs in the health and social sector accounting for more than 10% of total employment now in several OECD countries. This publication reviews key trends and policy priorities on health workforce across OECD countries, with a particular focus on doctors and nurses given the preeminent role that they have traditionally played in health service delivery.

Across the OECD, health outcomes have continued to improve, generation after generation. This would not have been possible without the efforts, skills and dedication of millions of health workers. The role of doctors, nurses and other health professionals in delivering health services to the population, thereby contributing to better health outcomes, stronger economies and more vibrant societies, is undeniable. The health and social sector now accounts for 10% of employment in our economies. As the health and long-term care needs of ageing populations grow in size and complexity, it is not surprising that this share is expected to rise, providing many more job opportunities.

Health workers are the cornerstone of health systems. Despite all the interest in selftreatment and the growing role of eHealth and mHealth, it is still – overwhelmingly – health workers that provide health services to the population. Jobs in the health and social sector now account for more than 10% of total employment in many OECD countries. In 2013, 3.6 million doctors and 10.8 million nurses were working in OECD countries, up from 2.9 million doctors and 8.3 million nurses in 2000.

Over the past decade, it has become increasingly clear that OECD countries need to adapt their health systems to changing population health needs and the growing burden of chronic diseases and mental health problems, moving to more team-based and patientcentred care models.

This first chapter takes a broad look at how health labour markets function. It presents a general framework for analysing the range of factors affecting both the supply of, and demand for, health workers. The discussion starts by presenting a basic supply framework, and then adds other components on both the supply and demand side. In all OECD countries, the functioning of the labour market for doctors, nurses and other health professionals is characterised by strong government interventions, affecting both the supply and the demand sides. The main rationale put forward for these government interventions is also discussed.

Prior to the economic crisis, there were widespread concerns in most OECD countries about a looming crisis in the health workforce. Growing shortages of health workers were expected to result from the retirement of the "baby-boom" generation of doctors and nurses and from steady increases in the demand for their services from an ageing population. However, these concerns have since lessened considerably in many OECD countries as countries have adapted their education and training policies leading to a growing supply of new doctors and nurses, and retention rates have also increased. This chapter describes recent trends in health labour markets in OECD countries before, during and following the economic crisis in terms of employment levels and remuneration rates, and considers key policy priorities of OECD countries in health workforce development and management. It finds that the employment of doctors and nurses has continued to increase both in absolute number and on a per capita basis, although the demand in some countries did not grow as quickly as expected following reductions in health spending after the crisis. The main health workforce priorities in many OECD countries have evolved from general concerns about widespread shortages to more specific issues regarding the mix and geographic distribution of certain categories of workers.

One of the most powerful policy levers governments can use to adjust the supply of doctors and nurses to projected demand is the so-called numerus clausus, that is, the regulation of the number of students entering medical and nursing education programmes. This chapter describes the evolution of numerus clausus policies in OECD countries over the past 15 years and key challenges in achieving an adequate number and mix of different categories of health workers. Since 2000, most OECD countries have increased substantially the number of students admitted to medical and nursing education, in response to concerns about current or future staff shortages. This has often been accompanied by deliberate policies to increase more rapidly postgraduate training places in general medicine vis-á-vis other specialties to strengthen the primary care workforce. A number of OECD countries have also introduced or expanded training programmes for advanced practice nurses such as nurse practitioners also to increase access to primary care by relying more on non-physicians. Following a strong and steady expansion in training capacity, some countries now worry about a possible over-supply of graduates entering the labour market. How might governments use more wisely these numerus clausus policies and the large amount of public resources spent in training future health workers? This chapter stresses that the health workforce planning models that are guiding these policy decisions need to better factor changes in population health needs and in the scope of practice of different health care providers that might impact on their future demand. These models also need to take into account the growing international mobility of students and health workers, which makes it more complicated to determine the "right number" to train at a national level.

This chapter examines recent trends in the migration of foreign-trained doctors and nurses in OECD countries and some of the policies that have affected these migration patterns. Between 2000 and 2014, the immigration of foreign-trained doctors and nurses increased in most OECD countries, although the number has generally slowed down in recent years as the number of domestically-trained doctors and nurses has steadily increased. Nevertheless, foreign-trained doctors and nurses have contributed to the overall increase in the number of doctors and nurses working in OECD countries since 2000. There have also been changes in the countries of origin of foreign-trained doctors and nurses, particularly in Europe. Some European countries that have recently become EU members and those particularly hard hit by the recession have experienced an important increase in the emigration (outflows) of their doctors and nurses to other European countries, seeking better job opportunities. While in some cases, this emigration might have helped to reduce the number of unemployed or under-employed doctors and nurses, in other cases, it exacerbated shortages of certain categories of doctors and nurses. This has prompted some countries, notably in Central and Eastern Europe, to take measures to increase the retention rates of doctors and nurses, including pay raises and improvements in working conditions.

The uneven geographic distribution of doctors is one of the most common health workforce policy challenges OECD countries currently face. This chapter provides an overview of this distribution challenge by presenting data on the number of doctors across different regions in OECD countries. It examines the reasons why doctors choose to take up practice in some places, but not in others, and analyses policy responses intended to tackle uneven distribution of doctors. Countries can use three types of strategies, possibly in combination: first, they can aim to select and train future doctors in such a way that they will hopefully distribute more evenly; second, they can try to influence the choice of practice location of new doctors through regulation and financial incentives; and third, they can reform health care delivery in order to be able to provide needed services with fewer doctors by extending the scope of practice of nurses, pharmacists or other providers. Telemedicine is also seen as another increasingly feasible and potentially more efficient option to connect patients and physicians at a distance. While the broad characteristics of these potentially useful interventions can be identified, more robust and regular evaluations are required to determine what policies work to tackle imbalances in physician supply in each context.

Health professionals need a wide range of complex skills to perform their work efficiently. However, as in other sectors of the economy, there is not always a perfect match between the skills that health professionals have and the skills required in their jobs. Such skills mismatch raises concerns of a possible waste in human capital (when people are over-skilled for the work they do) or the quality and safety of health services (when they are lacking certain skills). This chapter introduces the concept of skills mismatch among health professionals, proposing a broad framework to analyse both the possibilities of over-skilling and under-skilling. It presents some evidence on the extent of skills mismatch in the health sector by using information reported by doctors and nurses in the 2011-12 OECD Programme for the International Assessment of Adult Competencies (PIAAC) and the 2010 European Working Conditions Survey (EWCS). The results from these two surveys indicate that there tends to be a greater level of skills mismatch among doctors and nurses than among other workers in technical or professional occupations. This chapter then goes on to review some policy levers that might be used to address issues of skills mismatch in the health sector, including policies to expand the scope of practice of certain providers to reduce any over-skilling, and policies related to continuous professional development to ensure that the skills of health care providers remain up-to-date and "fit to practice".